WASHINGTON — Congress' efforts to overhaul the nation's health care system have been marred by confusion and a striking lack of consensus even among the ruling Democrats, despite intense but failed efforts by President Barack Obama and Democratic leaders to craft a plan by early August.

The House of Representatives adjourned Friday for a five-week summer recess with conservative and liberal Democrats still at odds over the cost and the government's role in any health care overhaul, putting off a floor vote until at least September.

In the Senate, bipartisan negotiators from its Finance Committee have been unable in weeks of talks to reach agreement on several items, notably how to pay for a $900 billion plan. They anticipate no deal before the Senate adjourns for a month on Aug. 7.

Despite White House claims that negotiators have reached agreement on 80 percent of any overhaul's terms, some of the most fundamental issues remain unresolved:

_ How many of the almost 50 million uninsured Americans will gain coverage?

_ How will the almost $1 trillion estimated 10-year cost of any overhaul be paid for?

_ How will ever-escalating health care costs be contained?

The prospects for success this fall are uncertain, at best. Polls show public support for the changes is eroding, and members of Congress face an August back home where interest groups and political parties are mobilizing to air ads, send e-mails and call radio talk shows in bids to build grassroots pressure behind their points of view.

"I think a lot of these issues are not well understood, and when you don't understand something, you're more susceptible to interest group pressures," said John Holahan, the director of the Urban Institute Health Policy Research Center.

Interest group pressures are coming from all ideological directions, said Ron Pollack, the executive director of Families USA, a health care consumer advocacy group.

"The interests are not always congruent. They include those who pay, and those who make money off health care," he said.

It wasn't supposed to be this way.

Obama, thinking that pressing Congress to meet a deadline would make lawmakers reach at least tentative agreements, badly wanted both houses to pass health care legislation before they left on vacation.

Obama made a nationally televised pitch on July 22, held town hall meetings around the country and sent his top lieutenants to the Capitol day after day for private talks.

House Speaker Nancy Pelosi, D-Calif., pushed hard for a vote by July 31. Senate Majority Leader Harry Reid said Tuesday that the Finance Committee would produce legislation by Aug. 7. Two days later, the panel's negotiators said otherwise: No final bill until after the August recess.

Too many obstacles impeded quick action.

Most obvious was an increasingly wary public. A July 22-26 Pew Research Center survey found that public support for Obama's health care initiatives is waning. Forty-two percent approved of his handling of the issue, down 9 points since April, and 43 percent disapproved, up 17 points.

In one especially ominous sign for lawmakers heading home: Of those Americans paying close attention, 56 percent oppose the plans now before Congress.

Lawmakers, especially those from partisan-swing areas, got the message. The Blue Dog Coalition, 52 moderate-to-conservative House Democrats from largely rural or small-town districts, is balking at what they see as too much government intrusion and out-of-control spending.

"People in my district know there are a couple of things they can count on — Medicaid, Medicare and Social Security. If the nation goes bankrupt, those things are gone," said Rep. Gene Taylor, a Democrat who represents Mississippi's Gulf Coast.

The Blue Dogs' struggle with liberal Democrats has been a major reason why House legislation stalled. White House Chief of Staff Rahm Emanuel and other administration officials brokered an agreement this week with four of the seven Blue Dogs on the House Energy and Commerce Committee, which has been writing a piece of the bill.

Then 53 liberal members of the House Progressive Caucus sent Democratic leaders a letter calling the Blue Dog pact "fundamentally unacceptable."

Pelosi remained publicly upbeat.

"We're all part of the same party. And we will have a bill that will come to the floor. And when it does, it will pass," she predicted.

In the Senate, the last hope for a significant pre-recess agreement rested with the Senate Finance Committee's six negotiators, three from each party. Though they reached tentative agreements on a number of issues, they've had trouble finalizing a way to pay for their $900 billion plan, among other core disputes.

Even if they and the House Democrats eventually agree on separate plans, significant hurdles will remain. House leaders must combine three committees' bills into one, and they may differ in significant ways. The Senate has to merge a liberal Health Committee measure with whatever compromise emerges from the Finance Committee, if one does.

If the House and Senate then both pass separate legislation, the next step will be for high-level negotiators to meet and cobble together a single measure, likely with intense White House involvement.

One major roadblock: Taxes. House Democratic leaders want to impose a surcharge on families with adjusted gross incomes of more than $350,000. Senators dislike the idea. Instead, they're looking at ways to tax insurance companies that offer pricey policies.

Lawmakers may compromise on taxes, but stress that they must be able to show their constituents that they'll get benefits too — that this isn't simply a liberal crusade to help the uninsured.

"More than any other issue, the devil is going to be in the details," said Sen. Olympia Snowe, R-Maine.

Any ultimate compromise would have to go back to each house for final approval. One ray of hope for Democrats: After Oct. 15, thanks to a change in Senate procedure, a health care bill would need only 51 votes to pass, not 60.

First, though, lawmakers must get through August's grassroots rallies.

Pelosi is arming House Democrats with pocket cards full of talking points about the need for health care changes. Cards are localized so members can cite how much local hospitals and health care providers could get for treating the uninsured.

Democrats also are targeting 24 Republican House districts with tactics that include radio ads, volunteer calls to talk radio stations, 3 million e-mails, and letters to the editor drives.

Republicans are ready with their own opposition campaign. The GOP is running radio ads against 60 Democrats in 33 states, charging that their health care plan is a "dangerous experiment."

Interest groups, too, will weigh in. Already, TV viewers have seen "Harry and Louise," a fictional middle-aged couple, talking calmly about the need to change the health care system, an ad from Families USA and the nation's drug manufacturers.

The Cato Institute, a libertarian research group, is countering with radio ads saying "they'd force you to buy insurance chosen by politicians and lobbyists . . . "

On the left, MoveOn.org plans to run local ads against Blue Dogs who oppose Democratic legislation, ads that charge the lawmakers "sided with the special interests and insurance companies."

When lawmakers return on Sept. 8, they'll face the problem that's vexed them all summer: How to design a plan that majorities in each chamber can support.

Few lawmakers seem confident that the mood will improve. Rep. Charlie Melancon, D-La., said that his standard is "something I can be comfortable with,' and that will depend on what he hears back home in August.

Sen. Ben Nelson, D-Neb., a swing vote, will explain to his constituents that "I'm not signing on to anything till I've seen everything." He lamented, however: "There are so many moving parts."

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